Scheduling abuse alleged at Houston VA

DeBakey center denies that patients' scheduling falsified

Executives with the Veterans Affairs medical center in Houston contend that they are "honest and straightforward when scheduling patients." Some disagree.

Photo: Johnny Hanson, Staff

Leading officials at the Michael E. DeBakey Veterans Affairs Medical Center have pressured clerks to make veterans' appointments appear to have been scheduled within 14 days of the patient's desired date - the system goal - when they are actually being seen significantly later, according to two sources and a formal complaint.

"Patients in need of a hearing evaluation are having to wait a minimum of 4-6 weeks to be seen in the Houston VA Medical Center audiology clinic," reads the complaint, made through the national VA's Office of Inspector General Hotline in December and obtained by the Chronicle this month. "Scheduling clerks have been directed to change the patient's desired date to the available date so that the facility's wait times meet the national directive."

Such subterfuge is done at the time of scheduling and after the fact, said former administrative officer Cynthia Cox and a clinician who spoke on the condition of anonymity. The clinician said the practice is still occurring.

A spokesperson for the Houston VA said top officials are not aware of any improper practices at the hospital.

The claims echo similar whistle-blower complaints about falsified records involving VA patient scheduling in Austin, San Antonio, Waco and around the country. Reports have attributed the practice to bonuses promised to executives for short patient wait times.

Following the first reports of such practices in Phoenix last month, the VA Office of Inspector General is investigating 26 facilities, a representative said Friday, up from 10 two weeks ago.

OIG officials would not disclose the identity of the facilities being investigated, but a spokesman at the Houston VA said it is not among them.

President Barack Obama on Wednesday called the scandal "disgraceful," if proved true, and he promised punishment for any misconduct. He said he has ordered VA Secretary Eric Shinseki to complete a preliminary review of the issue this week and his deputy chief of staff, Rob Nabors, to finalize within a month a broader survey.

The new Houston allegations were lamented Friday by U.S. Sen. John Cornyn, R-Texas, who this month railed against the VA's failings from the Senate floor, calling the long wait times and alleged efforts to conceal them "a betrayal of our nation's veterans."

"We've seen this go from a slow drip to a flood of allegations, and these latest claims highlight the systemic nature of this problem both in Texas and across the country," Cornyn said in an email to the Chronicle. "We must bring in new leadership immediately at all levels of the VA to ensure this culture of deception and gross mismanagement is rooted out once and for all."

U.S. Rep. John Culberson, R-Houston, a member of the House Appropriations Committee, added Friday in an email, "These are serious allegations. The men and women who fought for us on the battlefield shouldn't have to fight a bureaucracy at home. Houstonians know our veterans deserve better, and we must get to the bottom of these allegations to find what happened, fix it, and make sure it never happens again."

The Houston VA sources said they were not aware of any deaths associated with the delays in treatment.

Official denies problem

Maureen Dyman, communications director for the Houston VA, denied that administrators are directing employees to act inappropriately. She noted that VA auditors who met two weeks ago with Houston medical center officials didn't require any corrective actions be taken.

"To the best of our knowledge, gaming strategies have not occurred at the Houston VAMC," said Dyman. "A few weeks ago, the medical center director and associate director met with all schedulers over the course of a week to verify their knowledge and reiterated that they are to be honest and straightforward when scheduling patients."

Dyman said that since that meeting, none of the center's 700 employees with the ability to schedule patients has reported "a past or present issue."

She also noted that the Houston VA's internal investigation of the complaint made through the OIG hotline did not substantiate the allegation. The investigation looked at the data available for one day for audiology and one month for speech pathology and found that the appointments that could be verified were scheduled properly. Dyman said the matter was subsequently closed by the OIG.

But Cox and the clinician source told the Chronicle that appointment-scheduling manipulation is routine at the Houston VA. In the most common scenario, they said, clerks record as the patient's desired appointment date the first available opening given to them, without first asking them when they would like to be seen.

That would represent a flouting of VA training materials provided to the Chronicle. According to the guidelines, schedulers are supposed to ask the patient, "What is the first day you would like to be seen," then record the response as the "desired date." They should not enter a desired date that reflects an appointment date the patient acquiesced to accept for lack of any earlier availability, the guidelines say.

The clinician source gave one example of a 90-year-old World War II veteran who requested an appointment as soon as possible but could only get one for 96 days later, the first available. Because the clerk manipulated the schedule information to make the patient's desired date the same as the actual appointment, the clinician said, the scheduling data indicates a wait time of zero days rather than 96.

Seems above targets

In any case, the Houston VA seems to perform uncommonly well at meeting the federal system's goal patients be seen within 14 days. According to Dyman, 96.3 percent of patients in primary care, 99 percent in mental health and 98.6 percent in specialty clinics are seen in that time, well above VA targeted measures of success.

Cox and the clinician source allege that in those instances in which electronic records showed a significant discrepancy between the patient's desired appointment date and the date they were actually seen, top officials applied pressure on underlings to change the data.

"One particular time, I was told 'You've got to work this weekend because we've got to change these long lists of patients to meet the criteria of being seen with 14 days,' " said Cox, an administrative officer in audiology until she retired at the end of May 2013. "Audiology was always in trouble with the front office because we went by the rules."

Cox said she was asked to change such data often. She said she knew employees in Houston VA outpatient clinics who also were pressured.

Dyman said the hospital has no knowledge of such actions. She stressed that the investigation of the IOG hotline complaint found no wrongdoing, including by the two officials who oversee staff responsible for audiology scheduling.

Cox and the clinician source said gaming appointment scheduling has been going on at the Houston VA for years.

The practice was noted nationally in a April 2010 memorandum by William Schoenhard, the VA's deputy undersecretary for health administrative operatives. He wrote, "It has come to my attention that in order to improve scores on assorted access measures, certain facilities have adopted use of inappropriate scheduling practices sometimes referred to as 'gaming strategies.' " He wrote that "this is not patient centered care" and that "these practices will not be tolerated."

Todd Ackerman is a veteran reporter who has covered medicine for the Houston Chronicle since 2001. A graduate of the University of California at Los Angeles, he previously worked for the Raleigh News & Observer, the National Catholic Register, the Los Angeles Downtown News and the San Clemente Sun-Post.